Apple Health duration of use and dose limits for Proton Pump Inhibitors (PPIs)

Washington State Health Care Authority sent this bulletin at 04/17/2017 01:53 PM PDT

Apple Health (Medicaid): Provider Alert

New duration of use and dose limits for Proton Pump Inhibitors (PPIs)

Beginning June 1, 2017, Washington Apple Health (Medicaid), administered by the Health Care Authority (agency) will limit proton pump inhibitors (PPIs) to one tablet/capsule per day for two months during any 12-month period. The agency may authorize more than two months per year or more than one tablet/capsule per day for patients taking certain medications or who have one of the chronic medical conditions listed below.

Chronic NSAID use (including aspirin greater than or equal to 325 mg per day)

Chronic low-dose aspirin with history of a GI bleed

Chronic high-dose systemic steroid

Antiplatelet or anticoagulant

Bisphosphonate where there are pre-existing esophageal disorders and risedronate has been tried and failed

Pancreatic enzyme

Cancer therapies

Why are we adopting these interventions?

PPIs are commonly prescribed to treat gastroesophageal reflux disease (GERD) or heartburn, and symptoms are generally well controlled after 60 days of PPI therapy, even when cases are more severe. PPIs are known to cause rebound acid reflux when patients abruptly discontinue using the PPI. This rebound reflux is often mistaken for continued need of the PPI and has led to overutilization. Overutilization is defined as using a PPI for longer than the FDA-recommended time period of four to eight weeks. To avoid rebound acid reflux, the PPI should be gradually discontinued and supplemented with a histamine-2 receptor blocker (H2RA) (e.g. ranitidine 400 mg per day, over the course of a month). Thereafter, continuous or as-needed treatment with an H2RA should be sufficient for controlling symptoms caused by GERD.

Prescribers should:

Reevaluate therapy for patients diagnosed with GERD.

Gradually reduce the dose of the PPI over 30 days and discontinue, using an H2RA (e.g. ranitidine 400 mg daily) to reduce the occurrence of rebound acid reflux. See attached sample taper plan.

Discuss with their patients the guidelines on the management and treatment of GERD.

Consider endoscopy for patients unable to control symptoms caused by GERD after 8 weeks of PPI treatment followed by a 30-day cross-taper to an H2RA.

The American College of Gastroenterology (ACG) guidelines recommend the following for the treatment of GERD:

Weight loss

Head of bed elevation

Avoidance of meals 2-3 hours before bedtime

PPI for 8 weeks

Long-term use or high doses of PPIs are associated with the following risks:

Malabsorption of calcium leading to hypocalcemia could lead to bone fractures.

Malabsorption of magnesium leading to hypomagnesemia is potentially fatal. Magnesium levels should be monitored during PPI therapy. Symptoms include seizures, arrhythmias, hypotension, and tetany.

Increased risk of infection:

Clostridium difficile infections

Pneumonia due to aspiration of organisms not deactivated by gastric acid

Patients who do not have a chronic condition or are not using a concurrent medication as listed above should consider discontinuing the use of a PPI.

HCA oversees the state’s top two health care purchasers — Washington Apple Health (Medicaid) and the Public Employee Benefits Board Program. We work with partners to help ensure Washingtonians have access to better health and better care at a lower cost. For more information, visit www.hca.wa.gov.

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